Experts Define What Indian Nurses Must Master to Deliver Dignified End-of-Life Care

A team of Indian nursing researchers has built and validated the country’s most comprehensive competency framework for palliative care nursing, using a rigorous consensus method that drew on the expertise of health professionals from fifteen states. The study, published in BMC Nursing, arrives at a moment when the need for structured, culturally attuned end-of-life care in India has never been more urgent. Chronic illnesses are rising, the population is ageing, and emerging and re-emerging diseases continue to strain a health system in which access to palliative care remains limited despite substantial unmet need. Nurses, who often serve as the primary and sometimes the only caregivers at the bedside of dying patients, sit at the centre of this challenge, yet until now there has been no nationally validated standard describing exactly what they should know and be able to do.

The research, led by Soumya Liz Jacob and Malathi G. Nayak of the Manipal College of Nursing at Manipal Academy of Higher Education, with colleagues from institutions including the University of Edinburgh, set out to close a gap that has long been acknowledged but rarely addressed with methodological precision. Existing palliative care competency frameworks, most of them developed in high-income countries, assume healthcare systems, training pathways and scopes of nursing practice that do not translate cleanly to the Indian context. In India, family members frequently carry much of the hands-on burden of caring for the dying, specialist palliative services are concentrated in a handful of regions, and nurses themselves may receive little formal education in symptom management, communication around death, or the ethical dilemmas that surround end-of-life decisions. A framework imported wholesale from elsewhere risks being irrelevant at best and misleading at worst.

To build something genuinely grounded in Indian realities, the team began with a systematic synthesis of the published literature and paired it with a qualitative inquiry involving in-depth interviews and focus group discussions. From this dual foundation they drafted an initial pool of competency statements, each one intended to describe an observable skill, attitude or body of knowledge that a nurse providing palliative care in India should possess. The draft was then subjected to a modified electronic Delphi process, a structured technique for achieving group consensus that has become a mainstay of health-professional standards development. In a Delphi study, experts rate statements independently across successive rounds, receiving anonymised feedback about the group’s responses between rounds, which allows views to converge without the pressure dynamics of a face-to-face meeting.

The modified e-Delphi used here ran across three rounds and involved palliative care experts from across India, producing a geographically diverse evidence base that the researchers argue is essential for a country as heterogeneous as India. Consensus was defined in advance with statistical precision: a statement would be considered endorsed only if the median expert rating reached at least four on the rating scale, the interquartile range was no greater than one, and at least seventy percent of panellists agreed. Setting these thresholds before data collection protects the process from the criticism, common in weaker Delphi studies, that consensus criteria were chosen after the fact to fit the results. The researchers also reported their work according to the Conducting and Reporting of Delphi Studies guidance, and the trial was registered with the Clinical Trials Registry of India in July 2023, an unusual but welcome step for a study of this type.

The statistical machinery behind the study deserves attention because it illustrates how modern competency validation works. Beyond the descriptive consensus thresholds, the team examined changes in expert ratings between Rounds 2 and 3 for directly comparable statements using Wilcoxon signed-rank tests, a non-parametric method suited to paired ordinal data. Because they were testing many statements simultaneously, they applied the Benjamini-Hochberg correction to control the false discovery rate, preventing spurious signals of change from accumulating across dozens of comparisons. This combination of techniques reflects a broader trend in nursing science: the recognition that frameworks meant to guide education and policy must be built on transparent, reproducible quantitative foundations rather than on the intuitions of a small committee.

The results were striking in their consistency. Health professionals from fifteen states participated, and levels of agreement were high across all rounds. In the first round, most items were retained, while expert feedback prompted the researchers to merge overlapping statements, modify wording, delete redundancies and add missing content. By the final round, seventy-six of the seventy-seven statements met all the predefined consensus criteria. The single remaining statement fell short of the full statistical thresholds but was retained on the strength of its median rating and the qualitative feedback from the preceding round that had originally led to its inclusion, a decision the authors report transparently rather than quietly burying.

The final framework comprises nine domains and seventy-seven competency statements, and its architecture reads like a map of what dignified dying actually requires. The domains cover the foundations of palliative care; therapeutic communication; physical comfort and symptom management; multidisciplinary collaboration; psychosocial, emotional and spiritual support; end-of-life care; family and caregiver support; ethical and legal aspects of care; and, notably, nurse self-care and professional development. The inclusion of that last domain is significant. Compassion fatigue and burnout are well documented among clinicians who care for the dying, and a framework that treats the nurse’s own psychological sustainability as a competency, rather than as a private problem, represents a maturing of the field.

Several of the domains speak directly to the Indian context that motivated the study. Family and caregiver support, for instance, acknowledges that in India the family is typically the primary unit of care, and that a nurse’s job includes coaching exhausted relatives in symptom management, preparing them for the trajectory of decline, and supporting them through bereavement. The spiritual support domain reflects the profound religious and cultural diversity of the country, where rituals surrounding death vary enormously across communities and where a competent nurse must navigate them with sensitivity rather than a single template. The ethical and legal domain addresses questions such as advance directives and end-of-life decision-making that Indian law and clinical practice have only recently begun to confront.

The researchers are careful about what the framework can and cannot do. Its stated purpose is to support nursing education, clinical practice and policy, providing curriculum designers with a validated blueprint for training programmes, giving hospital administrators a benchmark for evaluating and developing staff, and offering policymakers a technical foundation for initiatives under the National Programme for Palliative Care. But the authors explicitly note that further work and commitments are needed to implement the framework in real-world practice. Validation of content is a beginning, not an endpoint; the framework must now be tested in educational settings, translated into assessment tools, and adopted by the institutions that train and employ India’s nurses. The study received no external funding, with open access support provided by Manipal Academy of Higher Education, and the authors declare no competing interests.

The significance of the work extends beyond India’s borders. The World Health Organization has repeatedly identified palliative care as an ethical imperative and a component of universal health coverage, enshrined in Sustainable Development Goal 3, yet the majority of the global need sits in low- and middle-income countries where specialist services are scarce and generalist nurses carry the load. A validated, context-specific competency framework offers those countries a template for strengthening the largest available workforce. For India, where millions of people each year need palliative care and receive none, the seventy-seven statements validated by experts from fifteen states are more than an academic exercise. They are a concrete statement of what good care at the end of life looks like, and a demand that the systems training nurses be held to it.

Subject of Research: Development and content validation of a palliative care nursing competency framework for India using a modified Delphi method

Article Title: Nursing competencies in palliative care for India: content validation using a modified Delphi approach

Article References: Jacob, S. L., Nayak, M. G., George, L. S., Noronha, J. A., Macaden, L., & R., V. (2026). Nursing competencies in palliative care for India: content validation using a modified Delphi approach. BMC Nursing. https://doi.org/10.1186/s12912-026-05416-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05416-y

Keywords: palliative care, nursing competencies, Delphi method, India, nursing education, end-of-life care, consensus framework, symptom management, nurse self-care, health policy, Nursing, competencies